PODCAST: Alcohol Deaths on the Rise and Suicide Declines

March 18, 2022


HOST:  The month of March is often associated with St. Patrick’s Day, which for some is also an occasion of heavy alcohol use.  NCHS has historically collected data on various health behaviors, including alcohol use, and since the arrival of the pandemic, vital statistics show that there has been a surge in alcohol-induced deaths, an increase from slightly over 39,000 deaths in 2019 to just over 49,000 deaths in 2020 – an increase of more than 25 percent.  Provisional data from 2021 show the number of alcohol-induced deaths have continued to increase, to more than 52,000, up 34 percent from pre-pandemic levels.

Chronic liver disease and cirrhosis is another, long-term adverse consequence of alcohol abuse, and those deaths have increased during the pandemic as well, from over 44,000 deaths in 2019 to over 56,000 deaths in 2021 – an increase of more than 26 percent.  Chronic liver disease and cirrhosis became the 9th leading cause of death of all Americans in 2021, up from 11th prior to the pandemic.

Drug abuse of course is a well-documented scourge in the country, and in March, NCHS released the latest monthly provisional tally of overdose deaths in the U.S., for the one-year period ending in October 2021.  105,752 people died of drug overdoses during this stretch.  Synthetic opioids, primarily fentanyl, accounted for the largest proportion of overdose deaths.

On March 17, NCHS released its latest estimates on emergency department visits in the United States from the National Hospital Ambulatory Medical Care Survey, documenting that more than 151 million ER visits occurred in the U.S. during 2019.

Earlier in the month, NCHS released a new studypdf icon looking at births during the pandemic.  The new report shows that the decline in births appears to have slowed during the first half of 2021, compared to the second half of 2020.  The decline in births during the first half of 2021 would have been even smaller except for a large drop during the month of January.

Finally, NCHS released the latest official trend report on suicide in America.  The latest trends were presented in November in a separate report, and we talked with the author of that report, Sally Curtin, about the latest numbers:

HOST: Despite other causes of death such as drug overdoses and homicides spiking during the pandemic, your data show suicide actually declined, correct?

SALLY CURTIN: Yes that is correct. The number, just under 46,000 in 2020, was 3% lower than in 2019 and also the rate of suicide per 100,000 population was 3% lower as well.  Now, this is actually building on a decline which actually had started before COVID.  There was the first decline in almost 20 years from 2018 to 2019 in suicide – of about 2% – and that’s after an almost steady increase in suicide between about the year 2000 and 2018… it had increased by 35% during that time

HOST: Was it a surprise that suicide dropped in 2020, particularly given the historic increases in homicide and drug overdose deaths?

SALLY CURTIN: That’s a good question because we do know – there’s documented evidence – that some risk factors for suicide definitely increased during 2020.  And some of those risk factors are mental health issues such as depression, anxiety… Also, substance abuse increased during 2020 as well as job and financial stress.  And those are known risk factors for suicide.  So, people were concerned that the actual suicide deaths would increase.  But in the very first sentence of our report we say that suicide is complex and it’s a multi-faceted public health issue.  So it’s not as easy to say, “OK, these risk factors went up for this cause of death; therefore, you know, the deaths are going to go up.”  Suicide is much more complex than that.  There are, as well as risk factors there are elements of, obviously, prevention as well as intervention.  So some of those factors – prevention and intervention – were definitely going on during 2020, and so therefore it’s hard to say and I think in general suicide is just harder to predict than a lot of other causes of death.

HOST: So then would you say that (with) the fact that suicide declined two years in a row, is this officially a new trend?

SALLY CURTIN: It’s hard to say.  I mean, certainly it’s positive in that it’s not continuing to trend upward as it had been for so many years.  But also let me point out it still is historically high – the number is historically high as well as the rate.  They’re both high over the last 20 years.  They’re just a little bit lower than the peak in 2018.  But certainly having two years of declines gives you some hope that it might continue.

HOST: Your new study looked at suicide during 2020 on a monthly basis – what were some things that stood out in your analysis?

SALLY CURTIN: For the most part, in early 2020 – in January and February – the numbers were higher than in 2019.  But starting in March they went lower, and pretty much suicide numbers in 2020 were lower than in 2019 for the rest of the year, except in the month of November where they were just slightly higher.  Now what really stood out is the month of April, where the suicide number in 2020 was 14% lower than in 2019, and that was the greatest percentage difference of any month. And we typically don’t see that big of a change year over year in monthly numbers, so that stood out.  And also it changed sort of the yearly pattern of suicides in general – the month that has the lowest number tends to be in the winter or maybe late Fall but in 2020, April was the month with the lowest number

HOST: That is interesting – would you say that it’s counter-intuitive given that everyone was in lockdown and a lot of people weren’t working etc?

SALLY CURTIN: You would think so and we definitely heard that calls to suicide hotlines just, they just blew up and one study said they went up 800%.  So we do know that people were stressed, but we also know that they were reaching out a lot and so… yeah it is (a surprise) – I think most people will be surprised there was that large drop in April.  And I’ll leave it to others to really sort of explain what was going on – you know, whether everyone was just sort of in shock or if the stigma of maybe reaching out wasn’t quite what it normally is during regular times.

HOST: It looks like the data suggest that the declines were pretty much across the board.  Is that correct?

SALLY CURTIN: Well, for females that’s pretty much correct.  And I mean by race and ethnicity groups – all of the groups for females were lower in 2020 than 2019.  And the greatest percent decline was for Non-Hispanic white females.  There was actually a drop of 10%, and that decline reached statistical significance.  But even for females the declines really started at age 35 and over. For the younger females ages 10 to 34, rates were either the same or actually increased a bit.  For males, there was a mixed picture.  Non-Hispanic white males, as well as Non-Hispanic Asian males, had a decline but groups of minority males had increases.  Non-Hispanic black men had an increase in their rates… Hispanic men… as well as Non-Hispanic American Indian men… And once again, for men, the groups for which there was a decline tended to be in middle-age or older ages, starting with age 35.  It was not apparent in the young people ages 10 to 34.

HOST: The increases among Non-Hispanic black and Hispanic and any other minority group – had these increases been happening prior to 2020 as well?

SALLY CURTIN: Yes, pretty much all of these groups that saw those increases from 2019 and 2020 had been trending upward.  The difference is for white and Asian, they had also been trending upward but now they’ve turned.  So yes, it was just a continuation of a generally upward trend.

HOST: Do you have any indications that the decline in suicide is continuing in 2021?

SALLY CURTIN: So far we do not have any provisional data for 2021 and something that is brought out in the report is that we don’t typically do suicide reports with provisional data because unlike other causes of death it can take longer to get an accurate cause of death saying that it’s suicide.  An example is in the context of a drug overdose.  Often, they have to do toxicology analysis to figure out if the intent was actually suicidal or if it was just accidental.  So for that reason suicide figures tend to lag behind other causes of death and unfortunately right now we don’t have any numbers at all for 2021.

HOST: OK, well any other points to add?

SALLY CURTIN: I think just you know that the overall decline – it’s probably unexpected or for a lot of people because there were known increases in risk factors.  But to just point out once again that although there was an overall decline, this was a lot driven by what happened with the majority group, with Non-Hispanic whites who have among the highest rates and the numbers of suicide.  So the fact that Non- Hispanic white women were down 10%, Non-Hispanic white men were down 3% , it sort of drove the overall decline.  And there were some groups that just did not experience declines – in fact, they experienced increases.  In particular, Hispanic men had an increase of 5% and that did reach statistical significance, but there were also increases for Non-Hispanic black men and Non-Hispanic American Indian men.  So it is encouraging that the overall rate declined, but we certainly need to continue to be vigilant and to realize that this decline was not experienced by everyone.

HOST: Alright, thank you Sally for joining us.

SALLY CURTIN: Oh sure.  Thank you.

QuickStats: Rates of Emergency Department Visits Related to Mental Health Disorders Among Adults Aged ≥18 Years, by Disorder Category — National Hospital Ambulatory Medical Care Survey, United States, 2017–2019

February 4, 2022

During 2017–2019, 52.9 ED visits per 1,000 persons were related to a diagnosed mental health disorder (MHD) in the United States per year.

Approximately one half of mental health–related visits had a diagnosis of a psychoactive substance use disorder at a rate of 27.1 visits per 1,000 persons per year, followed by an anxiety, stress-related, or other nonpsychotic mental disorder (14.4), mood (affective) disorder (12.6), other MHD (5.3), and schizophrenia, schizotypal, delusional, or other nonmood psychotic disorder (4.0).

Source: National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey, 2017–2019. https://www.cdc.gov/nchs/ahcd/ahcd_questionnaires.htm

QuickStats: Distribution of Emergency Department Visits Made by Adults, by Age and Number of Chronic Conditions — United States, 2017–2019

January 7, 2022

During 2017–2019, 38.5% of adult emergency department visits were made by patients with no chronic conditions, 22.9% made by those with one, 15.3% made by those with two, and 23.3% made by those with three or more chronic conditions.

The percentage of adult emergency department visits made by patients with no chronic conditions or one chronic condition decreased with age, from 58.0% among patients aged 18–44 years to 8.5% among patients aged ≥75 years with no chronic conditions and from 24.4% among patients aged 18–44 years to 18.5% among patients aged ≥75 years with one chronic condition.

In contrast, the percentage of visits by patients with two or three or more chronic conditions increased with age, from 10.5% among patients aged 18–44 years to 20.8% among patients aged ≥75 years with two conditions and from 7.1% among patients aged 18–44 years to 52.1% among patients aged ≥75 years with three or more chronic conditions.

Source: The National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 2017–2019. https://www.cdc.gov/nchs/ahcd/ahcd_questionnaires.htm


QuickStats: Rate of Emergency Department (ED) Visits by Homeless Status and Geographic Region§ — National Hospital Ambulatory Medical Care Survey, United States, 2015–2018

December 18, 2020


During 2015–2018, there were annual averages of 42 ED visits per 100 total population, 42 ED visits per 100 nonhomeless persons, and 203 ED visits per 100 homeless persons.

Within each region, the rate of ED visits among homeless persons was higher than the rate for nonhomeless persons.

The rates of visits for nonhomeless persons did not differ by region; however, among homeless persons, visit rates were higher in the West (268) than in the Northeast (127) and South (170) and higher in the Midwest (234) than in the Northeast.

Source: National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 2015–2018. https://www.cdc.gov/nchs/ahcd/ahcd_questionnaires.htm.


Opioid-involved Emergency Department Visits in the National Hospital Care Survey and the National Hospital Ambulatory Medical Care Survey

December 15, 2020

Questions for Geoffrey Jackson, Health Statistician and Lead Author of “Opioid-involved Emergency Department Visits in the National Hospital Care Survey and the National Hospital Ambulatory Medical Care Survey.”

Q: Why did you decide to research opioid-involved emergency department (ED) visits?

GJ: From 2005 through 2014, it is estimated that the rate of ED visits due to opioid use increased 99.4%, from 89.1 per 100,000 population in 2005 to 177.7 per 100,000 population in 2014. We were struck by the large increase and know that ED data can provide critical information on opioid use-related treatments, such as opioid use disorder treatment, detoxification for safe opioid withdrawal, and management of adverse effects. NCHS hospital surveys can be used to monitor trends in opioid overdoses, as well as other opioid-related morbidity and mortality measures.

Q: Can describe the difference between the difference between the National Hospital Care Survey and the National Hospital Ambulatory Medical Care Survey?

GJ: Even though both surveys collect data from hospital emergency departments, the mode of data collection differs between the two surveys. The National Hospital Care Survey (NHCS) is an all-electronic data collection of administrative claims or billing data. NCHS receives all inpatient, ED, and outpatient hospitals for a calendar year.  In addition, to patient demographics, diagnoses, procedures, laboratory tests, and medications, NHCS collects patient name, address, and Social Security number, which allows patients to be followed over time and linkage to external data sources, such as the National Death Index, providing a more complete picture of patient care and post-acute mortality.

In contrast, the National Hospital Ambulatory Medical Care Survey (NHAMCS) data collection relies on medical record abstraction by U.S. Census Bureau field representatives during a 4-week period. A random sample of about 100 ED visits are selected from all visits during the reporting period, and data are manually abstracted directly from medical records by Census staff. NHAMCS collects similar information as NHCS, but NHAMCS does not collect patient identifiers.  As a consequence, NHAMCS data cannot be linked to other sources nor can patients be collected over time.

Q: Was there a specific finding in the data that surprised you from this report?

GJ: One finding that surprised me was the increase in percentage the patients that died of an opioid overdose 90 days after their hospital visits. Specifically, of the patients with an opioid-involved ED visit that died with 91 and 365 days after their ED visit, 20.6% died with an opioid overdose, compared to approximately 15% that died within 90 days post-ED visit died of an opioid overdose.

Q: Is this the most recent data you have on this topic?

GJ: The most recent NHCS data available in the NCHS Research Data Center (RDC) are from 2016. The 2016 NHCS data are linked to the 2016 and 2017 National Death Index and include information on specific drugs mentioned on the death certificate from the Drug-Involved Mortality file. Additionally, the 2016 NHCS RDC data include identification of opioids using an enhanced methodology that uses natural language processing and machine learning techniques. The most recent NHAMCS public use data file available are from 2018.

Q: What is the take home message for this report?

GJ: NHCS is an important data source for studying opioid-involved ED visits. Through the collection of patient identifiers, the data can be linked to the National Death Index to provide information on post-acute mortality. The information on post-acute mortality is not available in other hospital data sources. Even though the NHCS data are not nationally representative, the NHCS data have similar distributions to NHAMCS data for national estimates of ED visits of male and female opioid-involved ED visits and for persons aged 35 and over.

QuickStats: Percentage of Emergency Department (ED) Visits Made by Adults with Influenza and Pneumonia That Resulted in Hospital Admission, by Age Group

December 11, 2020

During 2017–2018, 37.2% of ED visits for influenza and pneumonia by adults aged 18 years or older resulted in a hospital admission.

The percentage increased with age from 14.4% for adults aged 18–54 years to 46.9% for adults aged 55–74 years and 69.7% for adults aged 75 years or older.

Source: National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey, 2017–2018. https://www.cdc.gov/nchs/ahcd/ ahcd_questionnaires.htm.


QuickStats: Percentage of Emergency Department Visits for Acute Viral Upper Respiratory Tract Infection at Which an Antimicrobial Was Given or Prescribed by Age — United States, 2010–2017

February 14, 2020

From 2010–2013 to 2014–2017, the percentage of emergency department (ED) visits for acute viral upper respiratory tract infection that had an antimicrobial given or prescribed, hereafter referred to as ED visits, decreased from 23.4% to 17.6%.

A decline was also seen for ED visits by children, decreasing from 17.9% to 10.1%, but a decline was not seen for ED visits by adults. In both periods, the percentage of ED visits by adults was higher than the percentage of ED visits by children.

Source: National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey, 2010–2017. ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Datasets/NHAMCS.


QuickStats: Percentage of Emergency Department Visits for Pain at Which Opioids Were Given or Prescribed, by Geographic Region of the Hospital — United States, 2005–2017

January 17, 2020

The percentage of emergency department visits for pain at which an opioid was given or prescribed increased from 37.4% in 2005 to 43.1% in 2010 and then decreased to 30.9% in 2017.

A similar pattern was observed in all four regions. Percentages for the Northeast were lower than for the nation as a whole for all years analyzed.

In 2017, the percentage was 21.1% in the Northeast, compared with 32.0% in the Midwest, 32.0% in the South, and 34.7% in the West.

Source: National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey, 2005–2017. https://www.cdc.gov/nchs/ahcd/ahcd_questionnaires.htm.

Trends in Opioids Prescribed at Discharge From Emergency Departments Among Adults: United States, 2006–2017

January 8, 2020

Questions for Lead Author Anna Rui, Health Statistician, of “Trends in Opioids Prescribed at Discharge From Emergency Departments Among Adults: United States, 2006–2017.”

Q: Why did you decide to look at opioid prescribing at emergency department discharges?

AR: There is a large body of research reporting increases in opioid prescription rates from 1999 to 2010 but less is known about how rates have changed from 2010 on, particularly in the emergency department setting, where many patients present with pain symptoms and are likely to receive opioids for treatment. In response to the opioid epidemic, hundreds of local, state, and federal programs were implemented in recent years with the goal of changing prescribing practices. A goal of this report was to evaluate recent trends in opioid prescribing, in order to monitor the effects of public health policy.

Q: How did the data vary by patient/hospital characteristics and in the type of opioids prescribed at discharge?

AR: Variation in the rate of change was found for age, patient residence, and primary expected source of payment. The rate of decrease in the percentage of visits with an opioid prescribed at discharge by younger patients aged 18-44 from both the beginning of the study period (2006-2007) and from the inflection point (2010-2011) to the end of the study period (2016-2017) was the highest across all age groups. Similarly, the percentage of visits by patients living in medium or small metropolitan counties decreased by the highest percentage across the study period among all urban and rural categories. Both Medicaid and self-pay/no charge/charity experienced the highest rate of decrease from 2010-2011 through 2016-2017 whereas the percentage of visits by patients with Medicare that included an opioid prescribed at discharge remained stable across the study period.

In terms of hospital characteristics, among the four regions, the largest decrease in opioids prescribed at discharge from 2006-2007 to 2016-2017 was observed in the Northeast region. Generally, a higher percentage of visits at proprietary (or for-profit) hospital EDs, compared with nonprofit and government hospital EDs, included an opioid prescribed at discharge. Despite the high percentage, the rate of decrease among visits made to proprietary hospital EDs from 2006-2007 through 2016-2017 was modest.

In terms of the type of opioids prescribed, the percentage of opioid mentions with acetaminophen-hydrocodone (e.g., Vicodin) prescribed remained stable through 2012-2013 and decreased starting from 2014-2015. Corresponding to this decrease, the percentage of opioid mentions with tramadol and acetaminophen-codeine, which are known as having a lesser risk of dependence, increased starting in 2014-2015 and continued through 2016-2017.

Q: Was there a specific finding in the data that surprised you?

AR: One finding that surprised me was the magnitude of decrease in the percentage of opioids prescribed from 2010-2011 through 2016-2017 for most of the pain-related diagnoses. For example, the percentage of visits for extremity and back pain decreased by 68.8% and 49.1%, respectively, between 2010-2011 and 2016-2017.

Q: How did you obtain this data for this report?

AR: Restricted data (available from the Research Data Center) collected from the National Hospital Ambulatory Medical Care Survey were used for this report. Masked public use data are available for download from the Ambulatory Health Care Data website (https://www.cdc.gov/nchs/ahcd/datasets_documentation_related.htm)

Q: What is the take home message for this report?

AR: I think the take home message of the report is recent trends show a decrease in the percentage of visits with opioids prescribed at discharge from 2010-2011 through 2016-2017, and this trend was observed for most of the patient and hospital characteristics examined, as well as for most of the pain-related diagnoses prompting the ED visit.

QuickStats: Number of Emergency Department Visits, for Substance Abuse or Dependence per 10,000 Persons Aged 18 Years or Older, by Age Group — United States, 2008–2009 and 2016–2017

December 20, 2019

The rate of emergency department visits with a primary diagnosis or primary complaint of substance abuse or dependence by patients aged 18–34 years in the United States increased from 45.4 visits per 10,000 persons in 2008–2009 to 76.0 visits in 2016–2017 but remained stable among patients aged 35 years or older (27.2 in 2008–2009 and 24.6 in 2016–2017).

In both periods, persons aged 18–34 years were more likely to visit the ED for substance abuse or dependence than those aged 35 years or older.

Source: National Hospital Ambulatory Medical Care Survey, 2008–2017.